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Today on the blog, regular contributor Kathy Morelli shares information on an uncommon but very serious mental health disorder called pregnancy negation (pregnancy denial and pregnancy concealment) that can occur in women. This unusual phenomena may never have crossed your radar or you may have met women who have experienced this situation. Learn more here about this illness and what you can do as a childbirth professional, should you meet a woman or family dealing with this situation. – Sharon Muza, Community Manager for Science & Sensibility.

The research studies about negation of pregnancy generally consist of small sample sizes, so there isn’t a lot of data available about negation of pregnancy. More study is needed in order to understand this topic more thoroughly. I do see this phenomena in my psychotherapy practice, so I believe it’s a topic that birth professionals might see it in their community as well.

Negation of pregnancy, a term that encompasses both pregnancy denial and pregnancy concealment, are rare, but not uncommon, disorders of pregnancy. One in 475 pregnancies result in negation of pregnancy. A very minute portion of this statistic results in neonaticide- the act of killing a baby in the first 24 hours of life (Beier et al, 2006).

As with other psychological conditions, the underlying etiology of negation of pregnancy exists on a spectrum. The person can suffer from a lifelong, persistent “splitting” of the self due to trauma, she can suffer from a persistent biological mental illness, such as schizophrenia, or she can be experiencing a type of severe adjustment disorder.

Current research indicates that not all women who experience negation of pregnancy have previous diagnoses of serious and persistent mental illness. Some women who experience negation of pregnancy have pre-existing diagnoses of biploar with psychotic features and schizophrenia, and psychosis is part of their life experiences. But others do not have a previous diagnosis and after integrating the episode of negation of pregnancy, they adjust to their life situation and cope realistically.

Definition

Pregnancy denial is defined as a woman’s unawareness, in varying degrees, of her pregnancy. Pregnancy concealment is defined as actively deciding and hiding the pregnancy from others. Pregnancy denial and pregnancy concealment often co-occur and occur intermittently. There is usually a great deal of shame, fear, guilt and dissociation, a strong psychological and emotional defense, accompanying this disorder. Due to the level of emotional conflict around the pregnancy, there are gradations of denial and complexity and subtlety of emotional response from both the pregnant woman and those around her.

The term negation of pregnancy is also used to encompass and describe these co-occuring disorders, whereas the internal process is called denial and the external process is called concealment. Therefore, it is considered the same process, but the woman’s defense mechanisms vary in intensity.

Neonaticide, the killing of an infant on the day of birth, is a form of infanticide that is often preceded by pregnancy denial. Neonaticide can be one of the complications of pregnancy denial.

Pregnancy denial is a real phenomena that has a long history of documentation, by doctors, mothers, their families and artists.

One famous literary exploration of pregnancy denial and neonaticide is illustrated in George Eliot’s novel, Adam Beade, published in 1859. It is the novel of a woman’s experience, examining the intersection between women’s unique emotions around reproduction and their disempowered social standing. Taking place in 1799, the story is about a love triangle involving Hetty, a 17 year old girl. She becomes pregnant out of wedlock. Hetty knows she is pregnant, but never openly acknowledges this. She knows she will face extreme shame and ostracization by the town, should anyone find out. She successfully hides her pregnancy and gives birth to her baby in a field. She commits neonaticide, abandoning her baby boy where she birthed him.

Characteristics of Women Who Negate Pregnancy

Early research indicated that pregnancy denial and neonaticide is more likely to occur in women who are young and unmarried, where the relationship with the father is dissolving or non-existent and the woman lives at home with relatives.

However, more recent research shows that pregnancy denial and neonaticide occurs in women of all age groups, cultures and marital status in response to a conflicted pregnancy. Many women already have several other children, so it is not always the first time mother who negates her pregnancy.

Research by Shelton and colleagues (2011) indicates that pregnancy at an early age, multiple young children, a history of childhood abuse and trauma, current fear of abandonment (even if in a stable relationship), and a deprived social situation are all risk factors and common characteristics for women who negate their pregnancy.

The pathway to pregnancy denial and concealment often begins with an unplanned pregnancy. The woman has accompanying feelings of extreme fear and shame. She begins with pregnancy concealment. She hides her pregnancy with baggy clothes and isolates herself in her room. To help facilitate concealment, she sees less and less of people. Thus, she becomes more and more emotionally isolated.

Eventually, she finds she has no one to confide in. This results in a vicious cycle, and her emotional defenses develop a sense of pregnancy denial. The pregnancy denial is described by researchers as intermittent, her lack of self-awareness comes and goes and she is able to compartmentalize her pregnancy. She successfully dissociates from her body sensations.

The denial and dissociation is so potent that women often describe beginning birth pains as flu symptoms, gas pain and menstrual cramps. Women often go to the bathroom and deliver the baby silently, with others nearby. Women often describe the feeling of giving birth like having to defecate and are shocked when a baby appears.

Women in this type of delivery report dissociative symptoms at the birth and afterward when coping with the newborn. Women also often report a fantasy that the infant was preterm or stillborn. Often, sadly, the outcome for infants born to women who are experiencing negation of pregnancy are death a short time after birth, either from drowning in a toilet bowl, or hitting their head on the floor in a precipitous, unassisted birth.

Another fascinating aspect of pregnancy concealment and denial is that the family and even doctors are drawn into “community denial” by the emotional intensity of the denial. Interestingly, in one study, only 5 out of 28 women studied who negated their pregnancy had any family members inquire about their pregnancy at all (Amon et al, 2012)! Another study indicates that even long term family doctors who know the woman well will sometimes fail to diagnose the pregnancy (Amon et al, 2012).

Treatment

Treatment for negation of pregnancy is as nuanced and varied as each individual case. Whenever there is dissociation of parts of reality and parts of the self, the treatment path can include techniques used to treat post-traumatic stress. Such techniques would include EMDR, guided imagery, object relations techniques embedded in an overall therapeutic structure that balances leaving a woman’s psychological defenses intact, while at the same time helping her through her issues of denial (Anonymous, 2003).

Depending on the cause and severity of the negation of pregnancy, the processing of dissociated emotional material, the buried shame, the confusing physical symptoms, and the integration of the parts of her self could take place over an extended period of time in a safe, therapeutic atmosphere.

In general, directly asking or accusing a woman who is negating her pregnancy about her situation isn’t an effective treatment method. In order to survive, the person has most likely developed a method of dissociative “splitting” or “compartmentalizing” differing parts of the self. It is a normal psychological response to dissociate from trauma in order to survive. Dissociative coping exists along a continuum, from intermittent denial to having developed separate parts of the self to contain the trauma (Amon, 2012; Anonymous, 2003).

For example, in order to survive complex emotional trauma, such as childhood abuse, incest, rape, pregnancy from rape/incest, a woman would survive by dissociating. She may have unconsciously developed a way to “split” or “compartmentalize” parts of her self. Her unconscious coping mechanism assigns one part of the self to be covertly sexually active while another part of the self overtly maintains the social and familial facade that she is not sexually active. The psychological defenses can be so strong that she has intermittent dissociative awareness about her pregnancy and even amnesia around childbirth.

On the other hand, a woman may be experiencing a less mild form of dissociation and negation of pregnancy. She may need time to integrate her pregnancy into her life and shift towards healthy adjustment, coping and planning.

What birth professionals can do

If you suspect you have encountered a woman with this condition, be aware of your own reactions to her situation. Convey an accepting attitude about her situation. It’s best not to ask her overt questions about her circumstances. Ask open-ended questions, wait for her responses.

Importantly, convey an accepting attitude about sexuality, pregnancy and motherhood, without being overt.

Have a good set of referrals to health professionals, including mental health professionals, in your area. You may not be able to help her in the moment, but there may be another time you’ll see her and she might be open to accepting help. Your accepting attitude could be part of her healing and reaching out.

Conclusion

To sum up, negation of pregnancy has been documented in the popular literature and in medical literature for many years. It was once thought that negation of pregnancy only occurs in young and unmarried women, but current research shows that older women with multiple children experience this as well. It is a condition of many emotional and psychological nuances. In a very rare number of cases, can lead to neonaticide.

As a birth professional in your community, you can help by developing an awareness and understanding of negation of pregnancy as a real condition, with many emotional and psychological nuances. By being accepting and by having a solid set of referrals for her and her family if she reaches out to you. More study is needed in order to understand this topic more thoroughly.

Kathy Morelli is a Licensed Professional Counselor in Wayne, NJ and the Director of BirthTouch®, LLC. She provides Marriage and Family counseling in Wayne, New Jersey with a special interest in perinatal mood disorders, sexual abuse and its impact on parenting. EMDR is one of the mindbody therapies she uses to address trauma. She blogs about the emotions of pregnancy, birth, postpartum and couples. Kathy is the author of BirthTouch® for Parents-To-Be and BirthTouch® Healing for Parents in the NICU. Kathy has lectured on BirthTouch® at the University of Medicine and Dentistry of New Jersey’s Semmelweis Conference for Midwifery and at birth conferences. She presents trainings to allied health/birth organizations about maternal mental health, family systems and good-enough parenting and is found on web media, such as PBS’ This Emotional Life, writing and speaking about this subject. She volunteers on Postpartum Support International’s warmline. Kathy co-moderates #MHON , a psycho-educational and supportive Twitter chat led by credentialed Mental Health professionals around mental health issues, working to reduce the stigma around mental illness.

Regular contributor Walker Karraa has written an excellent three part series on Perinatal Mood and Anxiety Disorders (PMAD) and what the childbirth educator or birth professional can do to help women get the help they may need when dealing with mental illness during the prenatal and postpartum period. Walker interviews experts in the field who all offer concrete steps, activities and resources so that educators and others can do to be more prepared to discuss this important subject with students and clients. Recent press coverage of a British mother suffering from severe PMAD has made headlines and the topic is one that belongs in whatever childbirth class a woman chooses to take. – Sharon Muza, Community Manager.

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Safety regarding the use of a specific type of antidepressant medication, selective serotonin reuptake inhibitor (SSRI’s), is an important topic as maternal health care providers address the prevalence and negative effects of depression and other mood disorders in pregnancy and postpartum. Recently, the study The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond (Domar, Moragianni, Ryley & Urato, 2012) has garnered tremendous attention from media, researchers and childbirth professionals. I had the opportunity to ask the study’s authors and other experts about the dangers of discontinuation in a piece for Giving Birth With Confidence. From that article, we hear the overwhelming agreement; including two of the study’s authors, that sudden discontinuation of SSRI antidepressant medications in pregnancy is not advisable.

http://flic.kr/p/7oE1vk

A week later, I learned about the tragic case of Felicia Boots, a 35 year old woman in the United Kingdom who, fearing she was harming her baby by taking SSRI’s and breastfeeding, suddenly stopped. Shortly after, she took the lives of her 14-month old and 10 week old children. A special editorial published by The Lancet (November 10, 2012), noted: “She had stopped her prescribed antidepressants because she was convinced that the drugs would harm her baby through her breastmilk and feared that her children would be taken away from her”(p. 1621). The authors went on to state: “A society in which women know that they will receive empathy, understanding, and help might be one in which women seek advice more readily, and accept appropriate treatments” (Lancet, 2012, p. 1621).

This is a vision shared by the guiding principles of maternity care–as childbirth professionals have always worked for a society where women know they will be cared for, understood, and have access to appropriate interventions. Unfortunately, we have failed to include mental health. How might the childbirth education community better address these issues? Asking experts is a place to start. What is uniquely helpful here is that the same questions were given to all participants—shedding light on one commonality: education.

Today’s article features Julia Frank, MD. Dr. Frank is a Professor of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine and Health Sciences, where she has been the Director of Medical Student Education in Psychiatry since 2000. A graduate of the Yale University School of Medicine and of the residency program in psychiatry at Yale, Dr. Frank is also the founder of `Five Trimesters Clinic, a service for women with mental health needs relating to pregnancy and childbirth. In this installment, Dr. Frank addresses how childbirth educators might address these complex issues.

WK: How might childbirth professionals integrate an understanding of postpartum psychosis (PP) and other perinatal mood disorders in classes?

Dr. Frank: It is important to stress that the condition is rare but serious and treatment is generally quickly successful. Women with a family history of bipolar disorder or of postpartum psychosis in relatives should be told that they are at somewhat increased risk. Giving information in writing to them and their partners about what to look out for (especially profound sleeplessness and confusion) in the first couple of weeks postpartum might also be helpful.

How would you describe the stigma of perinatal mental health disorders and its impact?

Dr. Frank: I think the widespread publicity given to the sensational cases with terrible outcomes makes it hard for women to admit to any difficulty postpartum. The general public tends to conflate postpartum depression with psychosis. I have had women say to me “I don’t think I’m depressed, because I don’t want to hurt my baby”. We also overemphasize depression and neglect anxiety. I am not sure that is a factor of stigma, but it certainly contributes to under diagnosis.

http://flic.kr/p/PYHj7

Obstetricians and pediatricians may not recognize or discuss a postpartum psychiatric disorder for fear of offending the affected mother. Other aspects of stigma that apply to professionals are the belief that psychiatric disorders are overwhelmingly time consuming to address, that women who have them lack insight, that treatment is generally no better than passage of time.

WK: What do you see as the most significant barriers to treatment for women with perinatal mood and anxiety disorders (PMAD)?

Dr. Frank: In the US, the disconnection between mental health care and medical care, written into our insurance systems, is a major barrier. Also, the way pediatricians are trained to deal only with the child, and not to assume any responsibility for the health of the mother, keeps them from screening appropriately. Obstetricians also maintain an overly narrow focus on the woman’s organs, and they tend to have very little contact with mothers after delivery, nor do most of them see mental health as within their sphere of interest or expertise. Fears of liability from the effects on the fetus of treating the mother are another barrier, especially in the US, where medical injury to an infant can bring astronomically high damage awards. This is a particular barrier to some psychiatrists being willing to initiate or maintain treatment related to pregnancy.

WK: How would you respond to media-based concerns regarding the safety of SSRI medication in pregnancy?

Dr. Frank: There is no pregnancy without risk, and the risks of not treating a serious psychiatric disorder are as important to consider as the risks associated with treatment. When we bypass maternal suffering out of concern for the safety of a fetus, we are making a misguided moral judgment that privileges “innocent” life over life as lived. The risks of these drugs are important and should be weighed carefully, but it has taken literally decades and the review of the experience of tens of thousands of women to identify the risks. Absolute and percentage risks remain acceptable, when weighed against the known benefits of taking medication when necessary. Over fifty percent of pregnant women take something during pregnancy, and treating a mood disorder is as important as treating a UTI, or diabetes, or heartburn or any of the conditions that are typically addressed.

WK: What are your thoughts regarding discontinuation of medication in pregnancy?

Dr. Frank: Depends on the medication, the woman’s history, and the illness being treated. Certainly, discontinuing a medication should not be an automatic response to a woman becoming pregnant.

WK: What suggestions do you have regarding how childbirth organizations can encompass perinatal mental health into training curriculum and practice?

Dr. Frank: Widespread education in the use of efficient screening methods, particularly the PHQ 9 or the Edinburgh Postnatal Depression Scale would be a first step. Educators also need to develop routines for referring women to mental health services—the postpartum depression self-help community , embodied in organizations like Postpartum Support International, is pretty well organized and can help bridge the gap between screening and referral . Ideally, these organizations could reach out to women postpartum, rather than waiting for them to come in. Routine phone calls two and four weeks after delivery, providing encouragement for everyone while also identifying and facilitating referrals for women in difficulty, might be quite effective in both preventing and intervening in postpartum mood problems. This is an area that merits systematic study. Finally, organizations that include mothers themselves might consider urging women who have been identified and treated to write thank you notes to the health care providers who contributed to them getting help. I think this would counter the fears that providers have about giving and offense and doing harm.

Conclusion

Dr. Frank contributes to the broadening conversation regarding how childbirth educators might better address perinatal mental health. How do her suggestions resonate with your practice? In what ways could you use her information? Will you consider adding this information to your classes and new mother contact? And how could your certifying or professional organization become a source of support and education?

This is part one of a two part series on the support needs of women who experience postpartum psychosis, and their partners and is written by regular contributor Walker Karraa. Part two will run next week. – SM

It is important to note that this is the first published study looking directly at the support needs, preferences, and access to support for women who have experienced PP and their partners, and the importance of qualitative research in deepening our understanding of maternal health.

Creative Commons Image: Pamela Machado

As you know, qualitative research attempts to make explicit the lived experience of a phenomenon. Rather than quantifying an objective symptom in empirical methods and deducing what an experience is through external measurements, qualitative research methods put the lived experience of the individual center stage, and develop inductive strategies for learning about the human experience. In this study, for example, the authors use semi-structured interviews from mothers and partners to find themes in the content that may suggest more effective prevention and treatment strategies. Listening to mothers and using their subjective experience of PP and the needs they had in recovery offered a quality of information (data) that traditional quantitative data does not, and could not—by the very nature of its design and purpose. We cannot measure motherhood. But we can learn to listen to motherhood through multiple perspectives in order to learn its meanings and mitigate our advocacy.

2%-4% are at risk of harming their infants (Knopps, 1993; Spinelli, 2004).

PP has a 90% recurrence rate (Kendell et al., 1987).

According to the American Psychiatric Association (APA, 2000, p. 332), symptoms of PP include:delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior occurring within 4 weeks following childbirth, and that is not accounted for by other medical conditions, substance use, or mood disorders with psychotic features. Current research demonstrates that contrary to popular beliefs, PP is often the result of either bipolar disorder or major depressive disorder with psychotic features, and there is little frequency of PP caused by reactive psychosis or schizophrenia (McGorry & Connell, 1990).

Study Review

The goal of the recent JOGNN study Support Needs of Mothers Who Experience Postpartum Psychosis and Their Partners (Doucet, Letourneau, & Blackmore, 2012) was: “To explore the perceived support needs and preferences of women with postpartum psychosis and their partners” (p.236). A multisite, exploratory, qualitative descriptive design was implemented using a purposive sample of nine mothers (Canada, n = 7, United States, n = 2) and eight fathers (Canada, n = 7, United States, n = 1). Data were collected through one-on-one, in-depth, semi-structured, interviews lasting 45-120 minutes. Partners were interviewed separately. All interviews were audio-recorded and transcribed verbatim, and then analyzed using inductive thematic analysis in six phases based on the methods of Braun and Clarke (2006), thematic content regarding support for mothers emerged in the categories of (a) support needs; (b) support preferences; (c) accessibility to support; and (d) barriers to support.

Mothers’ Support Needs

Instrumental, Informational, and Emotional

Doucet et al., (2012) concluded that “all mothers reported the need for instrumental, informational, emotional, and affirmational support” (p. 238. Bottom line, the mothers needed good information about their illness, good information about taking care of an infant, and physical in home assistance.

Generic support of parenting needs included information on caring for newborn, and physical assistance with house cleaning and infant care. Following hospitalization for PP, the majority of participants described wanting 24-hour support at home. Some wanted help with physical needs of meal preparation, bathing, and assistance with confusion, disorientation, memory loss. Help with night feeding, holding, etc. were significant, as one mother noted:

It was helpful having people come over and play with him and take care of him, and if I am in that manic state I can just carry on and get it out of my system. (p.239)

Mothers reported needing reassurance that the cause of their illness was biological, that they would recover:

The turning point was when I talked to someone who had gone through the exact same thing as me. The fact that she turned out okay and went on to have a happy good life with other kids was reassurance that I could get through this. (p. 238)

Women also wanted specific information on PP including:

treatment options

medication safety when breastfeeding

long term prognosis

risk of relapse with future pregnancies

community support

Mothers’ Support Preferences

Mothers wanted clinical information from professionals, and emotional, affirmational, and physical support from informal networks—such as peers, partners, and families. There was a “strong preference” (p. 239) to receive physical help with baby from family, rather than formal sources such as in home nurses, etc.

All women wanted one-to-one, face-to-face support from a professional, at least once a week immediately after symptoms began. Once symptoms had improved, mothers reported preferring group support in face-to-face format, with mothers who had experienced postpartum mental health issues, and facilitated by someone with experience in PP, such as a professional, or a woman who had recovered from PP. They wanted to bring their babies to group sessions.

Access to Support

All mothers obtained access to a general psychiatric unit for immediate support with symptoms, but it is important to note they preferred a unit that specialized in postpartum mood disorders.

They felt they did not belong on a general unit, and did not receive specialized support. Most disturbingly, none of the women were able to see their infants, as is standard protocol in general psychiatric units, and found this extremely painful and hindered their recovery.

Barriers to Recovery

Barriers to recovery for the mothers in the study included the perception of health care providers as too clinical, uncaring, and having restricted their access to families. Isolation in the hospital, not seeing care provider, or feeling rushed in the appointment were also reported care-provider barriers. Family lack of knowledge about PP was reported as a barrier to recovery. One participant shared:

If my husband had a support group for new fathers to deal with a psychotic wife, it would have changed everything. He would have been far more compassionate had he known about my illness. He needed tools to deal with a mentally ill wife. (p. 241)

Finally, mothers in the study identified the lack of education regarding the differences between postpartum psychosis and other postpartum mood and anxiety disorders in family, peers and friends as a significant barrier to their own recovery. I think it is fair to offer considerations in approaching the topic so that together we will build a dialogue of difference, a conversation of consideration for how childbirth professionals process perinatal psychiatric illness, and learn to overcome fear through knowing.

In the next submission the findings from the fathers and partners will be reviewed, and considerations for childbirth professionals will be discussed.

Regular contributor Walker Karraa is currently the President of PATTCh, an organization dedicated to the Prevention and Treatment of Traumatic Childbirth. Walker is a doctoral student at Institute of Transpersonal Psychology, a certified birth doula, freelance writer, and maternal mental health advocate. She holds an MA degree in Clinical Psychology from Antioch University Seattle, and a BA and MFA degree in dance from UCLA. Walker is a contributor to the Lamaze sites, www.givingbirthwithconfidence.org and www.scienceandsensibility.com. She lives in Sherman Oaks, California with her husband, and two children.

Preterm delivery, delivery before 37 completed weeks of gestation, has been shown to cause significant morbidity in infants and to be a cause of lifelong health problems in these children. The World Health Organization (WHO) reports,

Preterm birth is a leading cause of neonatal and infant mortality as well as short- and long-term disability. Rates for preterm birth range between 6% and 12% in developed countries and are generally higher in developing countries. About 40% of all preterm births occur before 34 weeks and 20% before 32 weeks. The contribution of these preterm births to overall perinatal morbidity and mortality is more than 50%.”

Low birth weight—below 5 lbs 8 ounce (or 2500 grams)—is usually a consequence of preterm birth but is also a singularly significant cause of morbidity and mortality in neonates and children. According to the March of Dimes, 67% of preterm infants are low birth weight and in the United States, they estimate that about 1 in every 12 infants is born low birth weight.

Despite attempts to positively impact maternal health and nutrition, and aggressively treat preterm labor, the rates of preterm birth and low birth infants are still on the rise globally. Physicians and researchers continue to examine cases and studies trying to identify potential causes and treatments that could slow, halt and eventually reverse these trends. In 1996, Offenbacher et al first reported an association between periodontal disease and preterm birth. Since that time, evidence has been growing to support the idea that periodontal disease may be associated with preterm birth, low birth weight and other adverse birth outcomes.

Xiong and his colleagues reached this conclusion following a systematic review of the observational studies which showed that there is an association between periodontal disease and adverse birth outcomes (especially in lower socioeconomic populations), and meta analyses of randomized control trials (RCT’s); one in which preterm birth was the end point and one in which low birth weight was the end point. RCT’s performed in low to middle-income countries found a stronger link between treatment of periodontal disease during pregnancy and reduction in adverse pregnancy outcomes. RCT’s performed in high income countries such as the United States only showed that treating periodontal disease during pregnancy may reduce the rates of low birth weight. With these findings, Xiong and his colleagues present the following recommendations for future RCT’s to determine whether or not treating periodontal disease prior to conception can actually reduce the rates of preterm birth, low birth weight and other adverse pregnancy outcomes.

Study participants would be women planning to conceive within one year and with documented periodontal disease

Participants would be randomized to treatment vs. non treatment groups

Treatment groups would receive intense periodontal therapies and use of antibiotics to aggressively treat and eradicate periodontal disease

Endpoints of the studies would be delivery, and assessment of rates of adverse pregnancy outcomes would determine the efficacy of the intervention.

Xiong et al hypothesize that if preconception periodontal treatments reduce adverse pregnancy outcomes lowering infant morbidity and mortality, then improving oral health prior to pregnancy could be recommended, especially in low and middle income nations, as a means of reducing infant morbidity and mortality worldwide.

At face value Xiong’s hypothesis may seem like a lot of “ifs.” However, the presumed link between periodontal disease and adverse birth outcomes provides a simple portal for intervention and measurement of effect. While it may be more difficult to amass study participants as most women don’t receive preconception care, Xiong suggests recruitment within communities. He also suggests training of dental professionals so that the diagnoses and treatments of periodontal disease remain as uniform as possible worldwide.

I agree with Xiong’s hypothesis and proposed course of action. My concern is that here in the United States, many citizens are without dental coverage and will be unable to afford the preconception periodontal treatments should they become a standard of preconception care. While women may receive treatment during the study, how will low income and/or uninsured women receive such treatment once preconception treatment becomes a recommendation? Medicaid doesn’t cover dental procedures “for health” and preconception would need to be listed as treatment of overall health and that may prove a difficult task—at least initially. Medicaid is currently facing increasing budget cuts nationwide so adding another benefit may not be admissible, despite being effective in lowering other health care costs associated with the long term care of preterm and low birth weight infants.

While I hope that Xiong’s hypothesis is proven and preconception periodontal treatment is a solution to help reduce the rates of preterm birth and low birth weight infants, I fear that as a solution, it may not be available to many women, especially in the United States, due to costs. I hope that worldwide, if preconception periodontal treatment is effective in reducing adverse pregnancy outcomes, resources will be allocated for such treatment as it will reduce not only infant morbidity and mortality but also the burden of life long care costs for these children.

“There is no greater loneliness in the life of a human being than being alone with one’s own suffering; and no suffering is greater than the mental torture of impending agony from which there is no escape and of which there is no understanding.” Grantly Dick-Read, 1959, p.50

Grantly Dick-Read was right. Suffering alone breeds a sense of inescapable despair for which there are few words, if any. Lack of language is a kind of quintessential, ontological divide between a person’s experience and the observer’s understanding–what Biro (2011) noted as the starting point for change. Language can “replace isolation with community” (Biro, 2011, p. 15). This site is testimony to that! Listening to mothers is both our privilege, our scientific premise (the landmark study by the same name), and our standard of practice as childbirth professionals. In the spirit of listening to mothers, and learning to replace isolation with community–I would like to share a recent study regarding quite possibly the worst mental torture imaginable: suicidal ideation in pregnancy.

One of the first of its size and breadth, a recent study published in the Archives of Women’s Mental Health (2011) examined prevalence of suicidal ideation in a large sample of pregnant women. Two objectives were presented: (1) examine the prevalence of suicidal ideation and comorbid psychiatric disorders during pregnancy; (2) identify the risk factors for suicidal ideation during pregnancy:

“Although our understanding of the prevalence and consequences of antenatal major depression has improved, our understanding of suicidal ideation—a common aspect of major depression—during pregnancy is limited.” (Gavin, Tabb, Melville, Guo & Katon, 2011, p. 244)

Comparing prevalence rates of suicidal ideation in a pregnant population with those in general, non-pregnant population could substantiate or refute the commonly held belief that pregnancy is a protective mechanism against thoughts of suicide (Zajicek, 1981; Kendell, Chalmers, & Platz, 1987), offering a fuller vocabulary regarding this rare, yet tragic suffering. The authors built a strong rationale for their study by reviewing the scant literature that does exist, and its compelling evidence:

“Suicide is a leading cause of death among pregnant and postpartum women in the United States” (Gavin, et al., 2011 p. 239; Chang, et al., 2005).

The precursor to suicide in most cases is suicidal ideation, and the presence of major depression (Perez-Rodriguez, et al., 2008; Lindahl et al., 2005).

Women of childbearing years are at greatest risk for depressive disorders (Perez-Rodriguez, et al. 2008).

Authors employed a cross-sectional analysis design of data from a longitudinal study of 3,347 pregnant women receiving prenatal care at a single site university-based obstetric clinic (University of Washington) from January 2004 to 2010. After exclusion, the final sample size was 2,159 women. Study protocol mandated screening a minimum of two times, once in early second trimester, (16 weeks) and once in third trimester (36 weeks). Suicidal ideation was measured using the Patient Health Questionnaire (PHQ-9)–a screening instrument that has demonstrated both high sensitivity (73%) and specificity (98%) for major depression (Spitzer, et al., 2009). To examine suicidal ideation specifically, the authors measured women’s responses to item 9 of the PHQ-9:

“Over the last two weeks how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way? 0 = not at all, 1= several days, 2 = more than half the days, and 3= nearly every day.” (Gavin, et al., 2011, p. 241)

Participants self-reporting a score of 1 or greater (suicidal ideation several days a week in last 2 weeks), were considered positive for suicidal ideation. With the protocol in place, authors then applied multiple covariate logistic regression analysis.

Study Results

Results demonstrated 2.7% of the 2,159 sample scored positive for suicidal ideation–similar to the prevalence rates for general, non-pregnant populations recorded in both the National Comorbidity Survey 1990-1993 (NCS) 2.8% ; and the National Comorbidity Survey Replication 2001-2003 (NCS-R) rate of 3.3% in general, non-pregnant population:

“The prevalence of antenatal suicidal ideation in the present study was similar to rates reported in nationally representative non-pregnant samples. In other words, pregnancy is not a protective factor against suicidal ideation”. (Gavin, et al., 2011, p. 239)

Of the 2.7% prevalence rate:

78.0% reported thoughts of suicide “several days” in last 2 weeks

15.3% reported thoughts of suicide “more than half the days” in the last 2 weeks

6.7% reported thoughts of suicide “nearly every day”

52.5% experienced comorbid antenatal depression

15.7% experienced comorbid antenatal panic disorder

Speak My Language

Consider for a moment a group of 2,159 women attending standard prenatal childbirth education classes at a local hospital over the course of several years. Generalizing from this study and national statistics, 59 of them are having thoughts of ending their lives. Of those 59:

48 (78%) have considered killing themselves several days in the last two weeks.

9 (15.3%) have considered suicide more than half of the week,

4 (6.7%) of those moms have contemplated killing themselves nearly every single day.

And those are the women who admit it. The mothers who speak it. What do we do? Final recommendations put forth by the authors here included “efforts to identify those women at risk for antenatal suicidal ideation through universal screening” (Gavin, et al., 2011, p. 239).

I think it is pretty fair to say that the majority of childbirth educators and doulas are trained to screen for difficulties in breast feeding. When problems or risk factors present themselves, or a mom suffers from the agony of mastitis, we use language to help. We lean over the void of suffering and listen to our mothers.

We speak the language of lactation quite easily,
and have organizational support and training to do so.
Yet, how many of us feel comfortable with the language of suffering alone in major depression? Go to your certifying organization’s website and look for resources for moms, or family members who feel suicidal. Anything? For you as a professional certified by that organization to offer emotional support to your clients, are there resources there for you to access, to help your clients? Consider writing your certifying organization and request they update training for prenatal courses to include screening for depression. Ask them to post suicide prevention materials for consumers. Your organization(s) should offer assistance in learning how to screen, referral sources in your area, and after care resources for your own healing should you need it. Not doing so, not having public position papers, not speaking the language, in my mind is tantamount to silencing women’s suffering, and perhaps contributing to the loneliness of those who feel misunderstood. As David Biro (2011) states: “The consequences of silence are unacceptable…if we wish to relieve pain, we must first hear it” (p. 14).
“Listening to Mothers”…I’m in.

Posted by: Walker Karraa, MFA, MA

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Resources

The Suicide Prevention Life Line offers free buttons, logos and links to add to your websites, and free downloads to give clients/students. You can also call them yourself to ask them how to talk to a mom about her symptoms.